02-2013 Case of the Month

What would you do in this this case?

A 30-year-old woman, para 1, presents with a 3-cm Type II submucosal fibroid. Six months ago she had a miscarriage at 13 weeks' gestation and a sonohysterogram revealed the fibroid. She is considering another pregnancy but is unsure if she should treat the fibroid first. She wants to know what her risks of obstetric complications would be with a fibroid and with her fibroid treatment.

What would you do?

A.Explain that hysteroscopic myomectomy is associated with the lowest risk of complications compared to other intrauterine surgical procedures.

B.Tell her that fibroids are not related to miscarriage.

C.Let her know that fibroids double the risk of placental abruption.

D.Explain that the miscarriage rate is higher for myomectomy than uterine artery embolization.

Answer A is incorrect: Explain that hysteroscopic myomectomy is associated with the lowest risk of complications compared to other intrauterine surgical procedures. A prospective study of surgical complications of operative hysteroscopy found no statistically significant difference for endometrial resection versus myomectomy or polypectomy. Jansen et al. Obstet Gynecol 2000;96:266-70.

Answer B is incorrect: Tell her that fibroids are not related to miscarriage. Even when evaluating women who have fibroids that do not impact the cavity, there is near consensus that the presence of fibroids during pregnancy increases miscarriage rates. Although studies differ in method of diagnosing fibroids, documentation of fibroid size or location, study design and patient numbers, women with fibroids were more likely to experience pregnancy loss compared to women without fibroids.

Answer D is incorrect: Explain that the miscarriage rate is higher for myomectomy than uterine artery embolization. As an alternative to surgery, uterine artery embolization has been offered as an option for fibroid therapy. Data for non-reproductive indications suggest that a large fraction of women achieve symptomatic relief and avoid surgical intervention. However, when compared to myomectomy in women interested in reproduction, pregnancy rates are lower and miscarriage rates are higher among women who underwent embolization.

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